Quiburi Mission Nursing & Rehabilitation

Smoke Deficiencies

Install a fire alarm system that can be heard throughout the facility.

Miscellaneous Deficiencies

Have simulated fire drills held at unexpected times.

Emergency Preparedness Deficiencies

Establish staff and initial training requirements.

Smoke Deficiencies

Install corridor and hallway doors that block smoke.

Emergency Preparedness Deficiencies

Create arrangements with other facilities to receive patients.

Emergency Preparedness Deficiencies

List the names and contact information of those in the facility.

Resident Rights Deficiencies

Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.

Resident Rights Deficiencies

Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.

Resident Rights Deficiencies

Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.

Quality of Life and Care Deficiencies

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Egress Deficiencies

Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.

Smoke Deficiencies

Have approved installation, maintenance and testing program for fire alarm systems.

Services Deficiencies

Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.

Quality of Life and Care Deficiencies

Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.

Quality of Life and Care Deficiencies

Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail.

Construction Deficiencies

Install a two-hour-resistant firewall separation.

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.

Egress Deficiencies

Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.

Miscellaneous Deficiencies

Have simulated fire drills held at unexpected times.

Resident Rights Deficiencies

Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.

Resident Assessment and Care Planning Deficiencies

Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.

Resident Assessment and Care Planning Deficiencies

Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge.

Pharmacy Service Deficiencies

Ensure each resident’s drug regimen must be free from unnecessary drugs.

Administration Deficiencies

Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations (including nights and weekends) and emergencies.

Emergency Preparedness Deficiencies

Address subsistence needs for staff and patients.

Smoke Deficiencies

Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.

Smoke Deficiencies

Install corridor and hallway doors that block smoke.

Gas, Vacuum, and Electrical Systems Deficiencies

Ensure proper usage of power strips and extension cords.

E030 Names and Contact Information- No Entities, Facilities or StaffBased on review of the facility Emergency Plan (EP) record review, and staff interview, it was determined the facility failed to develop and maintain an emergency preparedness communication plan that complies with Federal, State and local laws and must include contact information related to staff, entities providing services under arrangement, next of kin, guardian or custodian, other facilities and volunteers be reviewed and updated at least annually. Failure to have an emergency preparedness communication plan that includes specific information could lead to harm to both patients and staff.

Based on a review of the facility's emergency plan and staff interview, it was determined that the facility failed to have the new and existing staff review the emergency preparedness plan. Failure to have staff review the emergency preparedness plan consistent with their expected roles may cause harm to the residents and/or staff during an emergency.

Based on observation and staff interviews, the facility failed to ensure that the electrical breaker for the fire alarm system has visual markings to distinguish it from other breakers. Failure to properly identify/mark the fire alarm system could lead to harm of 57 residents and staff in an emergency.

Based on observation, the facility failed to maintain several doors in the building. Failing to maintain doors in the facility could allow heat and/or smoke to transfer, causing harm to patients and/or staff in the affected areas.

Based on interviews and record review, the facility did not develop arrangements with other long-term care facilities and other providers to receive patients in the event of limitations or cessation of operations to maintain services to the facility's patients.

Based on a record review and interviews, the facility failed to provide all required fire drills per NFPA 101. Failing to conduct fire drills in accordance with the life safety code, one per shift per quarter under varied conditions, to familiarize staff with conditions under an actual fire, can result in harm to all residents and/or staff during an actual fire or emergency situation.

Based on clinical record reviews, facility documentation, resident and staff interviews, and policy review, the facility failed to protect the rights of one resident (#100) to be free from abuse by another resident (#200). This deficient practice could result in further instances of resident to resident abuse.

Based on clinical record reviews, facility documentation, resident and staff interviews, and policy review, the facility failed to protect the rights of one resident (#100) to be free from abuse by another resident (#200). This deficient practice could result in further instances of resident to resident abuse.Â